Contents
Ministerial Foreword 7
Introduction 9
Openness, honesty and candour 10
Listening to patients, families and staff 11
Finding and facing the Truth 12
Learning from errors and failures in care 13
People and professionalism 13
The right culture, from top to bottom 15
Freedom to Speak Up review 17
Introduction 18
Consultation process 19
Consultation responses and key themes 20
Overview 20
Analysis and implementation by policy area 21
Local implementation 21
Conclusion 24
Primary Care 25
Role of national bodies 25
Freedom to Speak Up Guardian Role 26
Independence 27
Shared role 28
Establishing the role 28
Costs 29
Training 30
Conclusion 31
Title of the local Freedom to Speak Up Guardian 32
Conclusion 35
Independent National Officer 36
Conclusion 36
Standards for Professionals 37
Conclusion 39
Strengthening legislation 39
Equality Analysis 40
PASC report 41
Executive Summary 42
Response to recommendations 46
Morecambe Bay Investigation 64
Executive Summary 65
[A] Recommendations for the Trust 67
Recommendations for the Trust: 1-18 67
[B] Recommendations for the wider NHS 69
Reviews: 19-22 69
Recommendation 19 69
Recommendation 20 69
Recommendation 21 70
Recommendation 22 72
Investigations: 23 73
Recommendation 23 73
Openness and transparency: 24-27 76
Recommendation 24 76
Recommendation 25 77
Recommendation 42 78
Recommendation 26 79
Recommendation 27 80
National standards: 28-29 81
Recommendation 28 81
Recommendation 29 81
Approach to investigations: 30 + 44 83
Recommendation 30 83
Recommendation 44 85
Complaints: 31 86
Recommendation 31 86
Midwifery Supervision: 32 89
Recommendation 32 89
National protocols: 33-35 90
Recommendation 33 90
Recommendation 34 91
Recommendation 35 92
Organisational change: 36-37 93
Recommendation 36 93
Recommendation 37 94
Perinatal deaths and recording: 38-40 95
Recommendation 38 95
Recommendation 39 96
Recommendation 40 97
Handling external reviews: 41-42 97
Recommendation 41 97
Focus on quality: 43 98
Recommendation 43 98
Annex: Recommendations 1-18 100
[A] Recommendations for the Trust 100